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Background  South Africa has continued to receive increasing attention due to unprecedented high levels of violence. Homicide-related violence accounts for a significant proportion of unnatural deaths and contributes significantly to loss of years of expected life. We investigated levels and factors associated with homicide-related deaths and identify communities with excessively high homicide risk in a typical rural South African population.    Method  Data drawn from verbal autopsies conducted on all deaths recorded during annual demographic and health surveillance in KwaZulu Natal, South Africa were used to derive the cumulative probability of death from homicide over a nine-year period (2000–2008). Weibull regression methods were used to investigate factors associated with homicide deaths. A Kulldorff spatial scan statistic was used to identify spatial clusters of homicide-related deaths.    Results  With 536 homicide-related deaths, and a median seven years of follow-up, the study found an overall homicide incidence rate of 66 deaths per 100, 000 person-years of observation (PYOs) (95 % CI 60-72) for the period under study. Death related to the use of firearms was the leading reported method of homicide (65 %) and most deaths occurred over weekends (43 %). Homicides are the second-most common cause of death in men aged 25–34 after HIV-related deaths (including TB) in this community, at 210 deaths per 100,000 PYOs, and was highest among 55–64 year old women, at 78 deaths per 100,000 PYOs. Residency status, age, socioeconomic status, and highest education level attained independently predicted the risk of homicide death. The spatial distribution of homicide deaths was not homogenous and the study identified two clear geographical clusters with significantly elevated homicide risk.    Conclusion  The high rates of homicide observed in this typical rural South African population – particularly among men – underscore the need for urgent interventions to reduce this tragic and theoretically preventable loss of life in this population and similar South African settings.

High rates of homicide in a rural South African population (2000–2008): findings from a population-based cohort study